Abdominal compartment syndrome and intra-abdominal hypertension in critically ill patients: diagnostic value of computed tomography.

AIMS: The aims of the present work were to reevaluate, prospectively, the diagnostic value of already-described computed tomography (CT) landmarks of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) and to study the diagnostic value of some undescribed CT signs for the diagnosis of IAH and ACS. MATERIALS AND METHODS: Consecutive patients admitted to the intensive care unit (ICU) in shock for whom an abdominal CT was clinically indicated were included. CT examinations were reviewed and scored by two reviewers for the 12 proposed CT features of IAH and ACS. Intravesical pressure (IVP) was measured for each patient. Imaging features and clinical data of patients with IAH (IVP ≥ 12 mmHg) were compared to those of patients with normal intra-abdominal pressure (IVP < 12 mmHg). RESULTS: Forty-one patients were included. Twenty-one patients (51%) presented IAH with an IVP value ≥ 12 mmHg. Four patients (10%) were considered to have ACS (10%). Only an increased peritoneal-to-abdominal height ratio (PAR) was associated with the presence of IAH (PAR = 0.45 [0.40-0.49] in patients with IVP < 12 mmHg and PAR = 0.52 [0.48-0.53] in patients with IVP ≥ 12 mmHg; p < 0.001). Increased PAR ≥ 0.52 had a specificity of 85% for IAH diagnosis. CONCLUSION: The present study suggests that a PAR ≥ 0.52 could help radiologists to identify IAH on abdominal CT scan and could lead to adequate identification and/or treatment, even at early stages of IAH. KEY POINTS: • CT is an efficient first-intention procedure to evaluate and follow up underlying conditions in critically ill patients at risk of IAH and ACS overcome. • Raising the possibility of an IAH on a CT examination is relevant information for the clinician. • The only factors associated with intra-abdominal hypertension were the peritoneal-to-abdominal height ratio (PAR) and the ratio of maximal anteroposterior to transverse abdominal diameter (which define the round belly sign when > 0.8).

[Prone position mechanical ventilation in the Acute Respiratory Distress syndrome: theoretical and practical considerations]. / Décubitus ventral et syndrome de détresse respiratoire aiguë de l'adulte: de la théorie à la pratique.

Mortality of the acute respiratory distress syndrome (ARDS) remains extremely high and only few evidence-based specific treatments are currently available. Protective mechanical ventilation has emerged as the comer stone of the management of ARDS to avoid the occurrence of ventilation-induced lung injuries (VILI). Mechanical ventilation in the prone position has often been considered as a rescue therapy reserved to refractory hypoxemia. Since the publication of the PROSEVA study in 2013, early prone positioning for mechanical ventilation should be recommended to improve survival of patients with severe ARDS. In this article, both the theoretical and practical aspects of mechanical ventilation in prone position are reviewed.

Preoperative plasma B-type natriuretic peptide (BNP) identifies abnormal transthoracic echocardiography in elderly patients with traumatic hip fracture.

INTRODUCTION: This prospective study was designed to evaluate whether preoperative plasma brain natriuretic peptide (BNP) could identify significant preoperative cardiovascular disease in elderly hip-fractured patients. PATIENTS AND METHODS: Preoperative plasma BNP measurement and rest transthoracic echocardiography (TTE) were performed within 24 h after admission in consecutive hip-fractured patients aged ≥65 years. The major echocardiographic abnormality (MEA) group included patients with at least one TTE abnormality, defined as systolic pulmonary artery pressure (PAP(s)) ≥50 mmHg, left ventricular (LV) systolic dysfunction, increased LV filling pressure (LVFP) or severe valvular disease. The control group included the remaining patients. RESULTS: Seventy-five patients (mean±SD (range) age=85±5 (69-97) years) were included during a 6-month period. Twenty-four (32%) patients constituted the MEA group (17 elevated PAP(s), three LV systolic dysfunctions, 10 increased LVFP, one severe aortic stenosis and one severe mitral regurgitation). Median (interquartile) preoperative BNP value was significantly greater in MEA than in the control group (527 (361) vs. 119 (154) pg ml(-1); p<0.0001). A preoperative plasma BNP cut-off value at 285 pg ml(-1) predicted well MEA with an area under the receiver operating characteristic (ROC) curve equal to 0.895 (p<0.0001) and with a hazard ratio (HR) (confidence interval, CI) of 23.8 (3.7-142.9) (p=0.0008) on multivariate analysis. The presence of MEA or BNP≥285 pg ml(-1) was associated with high mortality. DISCUSSION: The incidence of echocardiographic signs of elevated PAP(s) or elevated LVFP in elderly hip-fractured patients was high. A preoperative BNP value ≥285 pg ml(-1) can discriminate between elderly hip-fractured patients with or without MEA.

Occurrence of and risk factors for electroencephalogram burst suppression during propofol-remifentanil anaesthesia.

BACKGROUND: Suppression ratio (SR) derived from bispectral index (BIS) monitoring is correlated to EEG burst suppression. It may occur during deep anaesthesia, but also in the case of metabolic or haemodynamic brain injury. The goal of the study was to describe the occurrence of SR and to determine factors associated with SR during propofol-remifentanil general anaesthesia maintenance. METHODS: We conducted a post hoc analysis of BIS recordings in consecutive patients included in two multi-centre trials, undergoing non-cardiac surgery using a dual closed-loop BIS controller allowing automated propofol-remifentanil administration. The percentage of time spent with a BIS value between 40 and 60 (T(BIS 40-60)) was measured. Two groups of patients were defined: the SR group, including patients with at least one episode of SR value >10% lasting more than 1 min, and the control group. Factors associated with SR were analysed using a stepwise multivariate analysis. RESULTS: A total of 1494 patients [age=57 (17) yr; T(BIS 40-60)=76 (17%)] were analysed and 131 (8.7%) patients constituted the SR group. The main independent factors associated with SR were advanced age [odds ratio (95% confidence interval)=4.80 (1.85-12.43) (P=0.027), 10.59 (3.76-29.81) (P<0.0001), for categories of age 60-80 and >80 yr, respectively], history of coronary artery disease (CAD) [2.53 (1.47-4.37) (P=0.001)] and male gender [1.57 (1.03-2.40) (P=0.03)]. CONCLUSIONS: The occurrence of SR during BIS-controlled propofol and remifentanil anaesthesia is mainly observed in elderly male patients or in patients with a history of CAD. The mechanisms underlying SR and the potential consequences for the patient's postoperative outcome remain unsolved.

Systematic optimization of the clonal growth of human primary breast carcinoma cells.

Human breast carcinomas have been one of the most difficult tumor types to culture in agar-based clonogenic assays. This fact has limited their clinical applicability. We have used statistically motivated experimental designs to systematically improve the clonal culture of enzymatically monodispersed primary human carcinoma cells in an anchorage-independent agar system. Based upon an initial comparison of two basal media, we selected one which gave the best colony growth and then sought to optimize the individual additives in the medium. Hydrocortisone, fetal bovine serum, and red blood cells all improved both plating efficiency and median size of colonies derived from breast carcinoma cells. Next, the concentrations of these three components were simultaneously idealized using response surface methodology. By these methods, it was found that the optimal concentration of hydrocortisone was 0.35 microgram/ml, fetal bovine serum was 6.5%, and red blood cells was 2.1 X 10(7) cells/ml. Using these culture conditions, we have achieved plating efficiencies of 0.39% and 0.19% for colonies with diameters greater than 50 (50 cells) or 70 (130 cells) micron, respectively.

Surgical implications of intraoperative postinfarction ventricular rupture.

This case report documents that ventricular myocardial rupture after acute infarction may seal with clot, only to rupture again with potentially lethal consequences. At exploration, the clot over a fresh rupture was intact. As closure was started, the clot disrupted, causing severe hemorrhage. Rupture was successfully repaired and the patient survived.

Radiation survival of human mammary carcinoma cells: criteria for an agar-based clonogenic assay.

A human in vivo-in vitro model for breast cancer has been developed based on culture methods that were systematically optimized for solid breast carcinomas. A V-79 cell clonal agar-based model was used to define the analysis problem encountered with agar based clonogenic survival assays. Based on this, we established methods for the generation and analysis of the survival of primary and recurrent breast carcinomas following irradiation. Four out of five primary breast carcinomas studied had similar radiation-cell survival curves. The fifth tumor was more radioresistant. Interestingly, a recurrent breast carcinoma arising in a heavily irradiated chest wall was no more radioresistant than our series of unirradiated primary carcinomas. These methods may be useful both for the study of the radiobiology of human neoplasms and for customizing the treatments and prognosis of individual patients.

A comparison of methods for the production of monodispersed cell suspensions from human primary breast carcinomas.

Production of monodispersed cell suspensions from primary human breast tumors is difficult due to the predominant stromal composition of most breast tumors. Our studies were designed to optimize dispersion of breast tumors of known stromal content and histopathology. In a first series of experiments three enzymatic protocols were compared to disperse minced tissue: (A) treatment with collagenase (2 mg/ml) in the presence of 5% serum for 24 hours; (B) treatment with collagenase (6 mg/ml) and DNase (0.002%) in 10% serum for 3 hours; (C) treatment with collagenase (2 mg/ml) for 3 hours followed by pronase (0.075%) for 1 hour. Protocol A produced better cell yields than B or C for all tumors tested. The monodispersed cells were suspended in a 0.3% semi-solid agar with alpha modified Eagles medium (alpha MEM), 10% serum, and selected hormones, then layered over similarly enriched 0.5% semi-solid agar. The cells prepared by protocol A had a higher plating efficiency and larger average colony size than B or C. In a second series of experiments, protocol A was repeated and compared to two additional procedures: (D) treatment with collagenase (2 mg/ml) and hyaluronidase (1 mg/ml) in the presence of 5% serum for 24 hours; and (E) mechanical disaggregation. Protocol D exhibited a small but significant negative difference from A, while E was the least efficient in producing viable monodispersed cells from the tumors. All enzymatically monodispersed cells produced clonal growth in our agar system. However, mechanically dispersed cells gave growth in only 4 of 7 tumors. Protocol A, in addition to yielding the highest number of viable cells per gram of tissue, gave the highest plating efficiency of all protocols tested.